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INTRODUCTION

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This chapter describes the indications for surgery, technical aspects of surgery, and outcomes for patients with metastatic melanoma involving regional lymph nodes (stage III) or distant sites (stage IV).

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THERAPEUTIC OR COMPLETION LYMPHADENECTOMY FOR REGIONAL NODAL METASTASES

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Complete lymphadenectomy is currently the standard treatment for melanoma patients with identified regional nodal metastases. As a general principle, lymphadenectomy should be anatomic. The contents of the nodal basin are excised in a single block of tissue, preserving motor nerves and muscle whenever possible. Perioperative antibiotics are used routinely.1

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The goals of surgery include staging, regional control of disease, and possibly improved survival for some patients with clinically occult metastases identified by sentinel node biopsy. Indeed, the majority of patients who undergo lymphadenectomy today are now those who have histologically positive sentinel nodes. According to evidence-based ASCO/SSO guidelines, “completion lymph node dissection (CLND) is recommended for all patients with a positive SLN biopsy and achieves good regional disease control. CLND should be performed until there is convincing evidence that it does not improve regional disease control or survival.”2

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Patients with clinically suspicious nodes should be evaluated by fine-needle biopsy, if possible, with excisional biopsy done only if the results of fine-needle biopsy are indeterminate. Patients with bulky, biopsy-proven, nodal disease should be evaluated with baseline CT scans, a full blood count, and measurement of liver enzymes, including LDH, to rule out identifiable distant disease before proceeding with nodal surgery.

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The following sections describe some technical principles of lymphadenectomy in the axillary, ilioinguinal, and cervical regions.

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Axillary Nodal Dissection

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The goal of axillary lymph node dissection for melanoma is complete resection of all lymph nodes at levels I, II, and III.3 The long thoracic nerve and the thoracodorsal neurovascular bundle are left intact unless they are directly invaded by tumor. While division of the pectoralis minor muscle is rarely considered necessary for breast cancer, it is sometimes used for melanoma patients in order to obtain complete exposure of level II and III nodes. After removal of the axillary contents, a closed-suction drain is placed. Further details about surgical technique are described elsewhere.3 Patients undergoing a radical axillary lymphadenectomy should have no appreciable loss of range of motion or motor function. After a complete axillary dissection for melanoma there is approximately a 5% to 10% risk of symptomatic lymphedema of the upper extremity.

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Inguinal and Iliac Nodal Dissection

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For patients with metastatic nodes in the groin, an anatomically complete subinguinal (inguinofemoral) dissection is performed.4,5 In most cases a vertical incision is used, often with wide excision of an ellipse of skin over the femoral vessels, an area inevitably devascularised to some degree by the subsequent dissection. Flaps are then raised. The boundaries of the dissection extend superiorly to approximately 5 cm ...

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